Ridge preservation & augmentation /cosmetic dentistry course
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Transcript of Ridge preservation & augmentation /cosmetic dentistry course
www.indiandentalacademy.comRidge Preservation & Augmentation
INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
Part I• Introduction• Keys to bone graftingBone grafting materialsSocket grafting Part IIMaxillary sinus lift & sinus graft surgeryIntraoral autogenous donor bone graftsExtraoral autogenous donor bone grafts
Contents
Introduction
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Absence of infection Soft tissue closure Space maintenance Graft immobilization Regional acceleratory phenomenon (RAP) Host bone vascularization Growth factors BMPs Healing time Defect size & topography Transitional prosthesis
Surgical keys to bone grafting
Rapid solution mediated resorption in conditions of low PH
Absence of infection
Causes of graft material infectionEndogenous bacteriaLack of aseptic surgical techniqueFailure of primary soft tissue closureLack of blood supply in early stages
of grafting
Absence of infection
GuidelinesPrimary incision should be in keratinized
tissue
Soft tissue coverage
Crestal incisionis designed more lingualGuidelines to soft tissue closure
Vertical incisionsGuidelines to soft tissue closure
Vertical incisions are made to the height of MGJ & flap is retracted only 5 mm above the height of MGJ. This maintains more blood supply to the facial flap
Incision is not extended to mobile mucosa
Guidelines to soft tissue closure
Soft tissue reflection distal to graftSite is split thickness
Maintains some of the periosteum around incision line
Early vascularization of incision lineAdhesion of the margins to reduce retraction
during initial healing
Guidelines to soft tissue closure
2 techniques depending on
If less than 5 mm of advancement is necessary
To expand tissue over larger graft sites (15 x 10 mm) -- submucosal space technique
Techniques for soft tissue closure
For a small graft site
More apical tissue reflectionHorizontal scoring of the periosteum parallel
to primary incision
Techniques for soft tissue closure
Developed by Misch in early 1980sFull thickness facial flap is elevated off the
facial bone for 5 mm above the height of vestibule
One incision 1 to 2 mm deep is made through the periosteum parallel to the crestal incision and 3 to 5 mm above the vestibular height of periosteum
Submucosal space technique
Blunt dissection is done using soft tissue scissors (metzenbaum ) to create a tunnel apical to the vestibule & above the unreflected periosteum
Submucosal space technique
Thickness of facial flap should be 3 to 5 mm
Facial flap should be able to pass the lingual flap margin by more than 5 mm
Submucosal space technique
Disadvantages
Loss of vestibular depthLack of keratinized tissue on facial region of
grafted site
Submucosal space technique
Methods
Tent screws
Barrier membrane
Ti reinforced membranes
Graft material beneath the membrane
Space maintenance
Barrier by bulkConcept given by Misch
Methods of space maintenance
MethodsBone tacksTent screwBone screws work better with block bone
grafts than particulate
Graft immobilization / stability or fixation
Fixed transitional prosthesis
Indicated with barrier by bulk tech. using particulate material
Prosthesis should have rest seats & clasps to prevent loading soft tissues
Graft immobilization / stability or fixation
Local response to a noxious stimulus by which tissue forms faster than the normal regional regeneration rate
Healing is 2 to 10 times faster than normal physiologic healing
Begins within a few days after injury , peaks at 1 to 2 months usually lasts 4 months in bone & may take upto 6 to 24 months to subside
Regional acceleratory phenomenon
Decortication to induce RAP
Source of blood vesels Host cortical bone (few
arterioles Cancellous bone
(intensely vascular network
Blood vessels are needed to
Help the autograft maintain vitality
To repopulate the area with osteoblasts
Host bone blood vessels
Host site is decorticated with a rotary drill to
increase amount of host blood vessels at the
graft site
There should be spaces available between
graft particles for blood vessels to enter
Host bone blood vessels
Methods to increase tissue growth factors at graft site-
Use of autologous bone in graftPRPUse of allograftsRAP
Growth factors
Gerald D , Carlson ER , Gotcher JE et al
J of Oral Maxillofacial Surg 2006 : 64 (443 – 451)
PDGF mixed with autologous bone can accelerate mineralization by as much as 40 % during the first year
Growth factors
Factors affecting healing time
LocalNumber of remaining walls of boneAmount of autogenous bone in the
graftSize of the defect
SystemicDiabetes
HyperparathyroidismThyrotoxicosisOsteomalaciaOsteoporosis
Paget’s disease
Healing time
4 to 6 months -- graft volume is less than 5 mm
6 to 10 months -- graft volume is more than 5 mm
Healing time
Defect size effect following aspects of augmentation
Healing time
Vascularization
Transitional prosthesis
Graft material selection
Defect size & topography
Augmentation will be faster in an extraction socket surrounded by 5 walls than for a onlay graft on div D bone
Defect topography
Transitional resto. effectsSoft tissue closureMaintenance of space Immobilization of graft during healingRestores esthetics & functionContours the soft tissue
Transitional prosthesis
Transitional acrylic FPD
Metal reinforced acrylic FPD
Resin bonded prosthesis
Fixed temporary - eg temporaray implants
Removable restoration
Types….
Bone graft materials
Bone graft materials
collagenOsteogenic
Eg autologous bone
Osteoinductive
Eg DFDB
osteoconductive
SourcesBovine collagen from achilles tendon in
the legDFDB
Collagen barrier membranes used for GBR
Resorption rates vary from a few months to 1 year
Collagen
Autogenous trabecular bone
• Contains more osteoblasts• More osteogenic
Autogenous cortical bone
• Contains more bone growth factors• More osteoinductive
Autologous bone
Should remain vital to be able to produce osteoid
Recipient site is prepared first
Should be placed immediately after harvesting or
stored in
Sterile saline
lactated ringers solution
Guidelines for autogenous bone grafting
Should not be mixed with other synthetic graft materials
Guidelines for autogenous bone grafting
Decortication of host bone Directly placed on host bone
Guidelines for autogenous bone grafting
Phase I OsteogenesisBone regeneration by
surviving cells (osteoid)4 weeks
Phase II OsteoinductionBMP release2 wks to 6 months , peak
at 6 wks
Phase IIIOsteoconductionInorganic matrix
replaced by creeping substitution
Phase IVCortical plate acts as
a barrier membrane
Mechanism of bone growth within autogenous bone graft
The only osteogenic graft material
Osteoinductive property
Osteoconduction
Space maintenance- maintains contour of
desired augmentation
Advantages
Bone autografts
• Frozen bone• Freeze dried bone• Demineralized freeze dried bone
Allograftsosseous transplanted tissues from the same species as the recepient but of different genotype
Osteoinductive materials
Bone can be harvested , frozen & stored to be
used in the same patient at a later date
Allograft frozen bone is rarely used because of
risk of rejection & disease transmission
Frozen bone
Cortical & trabecular bone is harvested in a sterile fashion from a disease free donor
Washed in distilled water & ground to a particle size of 500 micron to 5 mm
Immersed in 100 % ethanol to remove fatFrozen in nitrogenFreeze dried & ground to smaller particle size of 250
to 1500 micron
Freeze dried bone
Marx RE , Wong MEJ of Oral & maxillofacial surg 1987 : 45 ( page
988)
Solvent prserved products have been
developed instead of freeze drying to reduce
antigenicity & assure a minimal risk of
contamination
Freeze dried bone
Ground bone powder is demineralized in 0.6 N
HCl or nitric acid for 6 to 16 hrs.
After acid bath it is washed & dehydrated
DFDB
Irradiation
• Doses greater than 2.5 Mrad are destructive to BMPs
Ethylene oxide sterilization
• 5 hr sterilization at 29 degree celsius to maintain osteoinductive properties
Sterilization
Age of cadaver
Type of bone Cortical bone contains higher conc. Of BMPs than trabecular bone Membranous cortical bone exhibits greater conc. Of BMPs than
endochondral cortical bone
Particle sizeParticles smaller than 150 micron are less effective than 250 micron
or larger
Fibres of cortical bone (eg grafton ) are more effective than particles.
Factors effecting OI property of DFDB
Putty consistency products
Fillers do not participate in bone formation
Recent advances
Allografts
•Freeze dried bone
Alloplasts
•Ceramics•Polymers•composites
Xenografts •Fabricated from inorganic portion of bone from animals other than humans
Osteoconductive materials
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Bioinert
•Aluminium oxide•Ti oxide
Bioactive
•Ca Phosphate•Synthetic HA•Bovine derived bone matrix•Tricalcium phosphates•Calcium carbonates
Osteoconductive materials(ceramic alloplasts)
•Non resorbable•resorbable
•Dense•porous
•Crysstalline•amorphous
Osteoconductive materials
Ridge preservation
Atraumatic tooth extraction
Socket grafting
Periosteum should not be reflected if bone
volume is ideal as it helps bone remodellimg
or repair
Soft tissue drape around the tooth is also
affected by reflection of periosteum
Atraumatic tooth extraction
An incision within the sulcus is made preferrably with a thin scalpel blade , 360 degree around the tooth
Atraumatic tooth extraction
Tooth to be extracted should be reduced mesio distally if the path of removal is obstructed by adjacent teeth
Atraumatic tooth extraction
Time period for socket regeneration is usually 3 to 6 months depending on
Tooth sizeRoot no.No. of bony walls around the socketSize of alveolusTrauma of extraction
Socket regeneration
In 1993 Miesch & Dietsh suggested different graft materials & techniques based on the no. of bony walls remaining after tooth is removed-
5 bony wall defect4-5 wall defect2-3 wall defect1 wall defect
Socket grafting
Any resorbable graft material such as alloplast , allograft or autograft
5 bony wall defect
Socket grafting is indicated ifLabial plate of bone is missingOne of the lateral plates is thinner than 1.5
mmHeight is desired
2 techniquesBM with a mineralized alloplast or freeze dried
boneModified socket seal surgery
4 – 5 wall bony socket
A periotome or thin periosteal elevator is used to tunnel under the bone periosteum
BM with alloplast or FDB
barrier membrane is then slid into the pocket created under the tissue & it extends apical , mesial & distal beyond the extraction site
Approx 6-8 mm of BM should extend above the marginal tissue
BM with alloplast or FDB
Bone graft material is placed & BM covers the top of the socket & is tucked in below the palatal tissue
BM with alloplast or FDB
Developed by Misch et al
It’s a composite graft consisting of connective tissue , periosteum & trabecular bone used to seal a fresh extraction socket
J of Oral Implantology 1999 ; 25 (pages 244 – 250 )
Socket seal surgery
AdvantagesCT graft blends into the surrounding attached
gingiva , offering similar colour & texture of the epitheliumcontains autogenous bone
Blood supply is established from the surrounding soft tissue
Rapid healing (4 – 5 months )
Socket seal surgery
• Treated similar to 4 wall defect
Defect size is larger so more bone is reqd.
2 -3 bony wall defect
Block graft or cortical autogenous bone
1 wall bony defect
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Misch in 1990, Implant Dent 1993 ;2 (pages 158- 167)
Layers in GBR include the followinghost bone -: decorticated to enhance blood supply , growth
factors & RAPAn autograft-: results in more predictable & rapid bone
growth by osteogenesis & osteoinductionMixture of DFDB (30%) , FDB (70%) , & PRP --: Provides
growth factors & space maintenanceBM & Tent screw -: BM prevents fibroblasts from invading the graft site for at
least 6 wks. Tent screw decreases mobility
Primary closure without tension -: prevents contamination & loss of graft material
GBR : the layered approach
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To be continue
d...
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Sinus grafting was introduced by Tatum in 1970s
In early 1970s Tatum began to augment post. Maxilla with autogenous rib bone to produce adequate vertical bone for implant support
In 1974 he developed modified caldwell luc procedure In 1975 he developed a lateral approach surgical
technique toelevate sinus membrane & place implant simultaneously
From 1974 to 1979 primary material for sinus grafting was autologous bone. In 1980 , Tatum introduced the use of synthetic bone
Maxillary sinus graft surgery
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Initial publication on sinus grafting was by Boyne & James in 1980s
In 1983 Misch observed that the most predictable intraoral region to grow boneis the max. sinus floor once the mucosa has been elevated
Maxillary sinus graft surgery
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Root tips in the antrumPseudocystsOral antral openingExtraction of hopeless teethUnerupted teeth
Conditions of concern to sinus grafting
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Narrowing of osteomeatal complexEnlargement of an air cell in the roof of sinus
( haller cell )
SmokingSmokers have a 7 % greater failure rate than non
smokersPt. should refrain from smoking at least 15 days
before surgery & 4-6 weeks after surgery
Chronic maxillary rhinosinusitis
Relative contraindications
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Active sinus infection on the day of surgerySignificant recurrent history of chronic
sinusitisSignificant recurrent history of fungal sinusitisUncontrolled late stage diabetesCystic fibrosismaxillary sinus hypoplasiaNeoplasmsInferior turbinate or meatus pneumatization
Absolute local contraindications
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Antimicrobial medication Administered at least 1 full day before surgery &
extended for 5 days after surgery
Local antibiotic medications To ensure adequate antibiotic levels in a sinus
graft , it is recommended to add antibiotic to the graft mixture
Mabry TW , Yukna RA J Periodontology 1985 ; 56 (74 – 81)
Premedications
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Oral antimicrobial rinse Gentle oral rinses of chlorhexidine gluconate 0.12 %
should be used twice daily for 2 weeks after surgery
Glucocorticoids Initiated 1 day before surgery & continued foe 2
days after surgery to control oedeme
Decongestant medications Oxymetazoline (0.05%) Phenylephrine (1% )
Premedications
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Analgesics Codeine containing drugs such as tylenol 3 are
the drug of choice as they have a potent antitussive effect
Cryotherapy Cold dressings for the first 24 – 48 hrs ,elevation
of head & limited activity for 2-3 days helps reduce swelling
After 2-3 days heat may be applied to increase blood flow & lymph flow
Premedications
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In 1984 Misch organised a treatment approach for posterior maxilla based upon the amount of bone below the antrum
Treatment classifications for posterior maxilla
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in 1995 , Misch modified his classificationto include the lateral dimension of sinus cavity to modify the healing period protocol
Smaller width sinnus (0-10 mm) -: less healing time
Larger width(> 15 mm) -: more time
Treatment classifications for posterior maxilla
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SA1 conventional implant placementSA2 sinus lift & simultaneous implant
placementSA3 sinus graft with immediate or delayed
endosteal implant placementSA4 sinus graft healing & extended delay of
implant insertion
Surgical technique
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Indicated when sufficient bone height is present for the placement of endosteal implants
Evaluation of sinus is less critical
Implants left to heal for 4-8 months
Progressive loading suggested in d3 & d4 bone
SA1 conventional implant placement
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Root form implants are used
At least a 12 mm in height implant for a 4 mm threaded implant
SA1 in Div A bone
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Osteoplasty or augmentation is suggested to increase width of bone
Augmentation may be done byBone spreadingAutogenous onlayAppositional grafts
SA1 in div B bone
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Onlay autogenous bone grafts are indicated
SA1 in C-w bone
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indicated when10-12 mm of vertical bone is presentTatum originally developed the technique in 1970 &
Misch published it in 1987Antral floor is elevated through implant osteotomy
by 0-2mmCompresses the bone below the antrum , causes a
greenstick fracture in the antral floor & slowly elevates the unprepared bone & sinus membrane over the broad based osteotome
Prosthetic treatment similar to SA1 after 4-6 months
SA2 : sinus lift & simultaneous implant placement
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SA2 procedure
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SA2 procedure
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Indicated when at least 5 mm of vertical bone & sufficient width are present between the anral floor & crest of residual ridge
SA3 : sinus graft with immediate or delayed endosteal implant placement
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Anesthesia Maxillary branch of trigeminal nerve is blocked Long acting anesthetic such as bupivacaine(0.5%) or
etidocaine(1.5%) is preferred
Incision line & reflection Crest incision is made on the palatal aspect of maxilla from
tuberosity to one tooth anterior to the anterior wall of sinus Vertical relief incision is made on the distal to enhance
access to max. tuberosity Anterior incision is made at least 10 mm ant to the ant wall
of sinus
SA 3 procedure
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Access windowTatum access window is 2-5 mm above the
antral floor , 2-5 mm from the anterior wall 15 mm long & 10 mm in height
SA 3 procedure
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Carbide bur in paint brush stroke is used to outline the access window
SA 3 procedure
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Flat ended metal punch & mallet is used to lightly tap & green stick fracture the access window from the lateral wall of maxilla
SA 3 procedure
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Sharp blade of the curette is placed against the inner wall of bone & is used to scrape off the sinus membrane from the bone
SA 3 procedure
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Layered approach to grafting
SA 3 procedure
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Implant placement
SA 3 procedure
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Soft tissue closure
Soft tissues & periosteum must be approximated for closure without tension
SA 3 procedure
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Indicated when less than 5 mm bone exists between sinus floor & crest of residual ridge
SA 4 : sinus graft healing & extended delay of implant insertion
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Lateral wall approach is performed for sinus graft as in SA 3 procedure
Medial wall of sinus membrane is elevated at least 16 mm fron the crest so that adequate height is available for implant placement
If bone from max tuberosity is not enough , additional bone may be harvested from above the roots of maxillary premolars or mandibular ascending ramus
SA 4 Procedure
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Intra operative Membrane perforation Antral septa Bleeding
Short term Incision line opening Paresthesia Acute maxillary rhinosinusitis
Long term Oroantral fistula Maxillary surgical cysts
Complications
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Intra oral donor sites
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Mandible Symphysis Body Ramus
Maxillary tuberosityExtraosseous toriRidge osteoplastyExtraction sitesImplant osteotomy
Intraoral donor sites
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Convenient surgical accessNo cutaneous scarPatients report minimal donor site discomfortInherent biological benefits attributable to the
embryologic origin of donor boneExperimental evidence shows that grafts from
membranous bone show less resorption than endochondral bone. Maxilla & body of mandible are membranous bones
J Oral Maxillofacial surgery 1996 : 54 (15-20)
Advantages of intraoral over extraoral donor sites
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Early revascularization of membranous bone grafts helps in improved maintenance of graft volume
Bone from the maxillofacial skeleton contains increased concentration of growth factors & BMPs
Plastic reconstructive surgery 1994 : 93 ( 732 – 738)
Improved survival of craniofacial bone grafts is caused by their 3-D structure
J oral maxillofacial surg 1996 :54 (15 – 20 )
Mand. Cortical bone grafts show little volume loss & show good incorporation at short healing times
Advantages of intraoral over extraoral donor sites
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In 1992 Misch et al used mandibular symphysis & ramus bone grafts for endosteal dental implants
J of oral maxillofacial implants 1992 : 7 ( 360 – 366 )
Bone grafts from mandible
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Symphysis
Ramus
Donor sites in mandible
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Easier graft harvestLess post – op discomfortLess neurosensory complicationsLess incision line openingLess anesthesia reqd.More profound LA with fewer drugsLess concern of changes in facial
morphology
Advantages of ramus as donor site
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Less width & length of bone
Disadvantages of ramus as donor site
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Slight curved triangular shape in the midlineis often well suited for re-establishing the arch form in maxillary anterior ridges
Average interforaminal distance is greater than 4 cm , so more bone volume is available
Advantages of symphysis as donor site
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Width & height requirements for augmentation
Mandibular symphysis : when more than 4 cm of bone is desired ( C-w bone volume )
Mandibular ramus :when graft width is less than 4 mm ( div. B to B-w bone volume )
Mandibular symphysis along with its cortical inferior border : when an augmentation for height is required
Factors affecting mandibular donor site selection
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Location of the host or recepient site
Factors affecting mandibular donor site selection
Recepient site
•Anterior mandible•Posterior mandible•maxilla
Donor site•Symphysis•Ramus•ramus
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host site prepration
Bone harvest
Graft fixation
Post operative instructions
Grafting procedure
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Host site prepration
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Host site prepration
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Host site prepration
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Bone harvesting
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Guidelines for symphysis bone harvest to augment width
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Guidelines for symphysis bone harvest to augment height
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Presence or absence of molarsWidth & height of external oblique ridge in the
body of the mandibleDistance from the external oblique ridge &
ramus to the inferior alveolar nerveWidth of posterior ramus is evaluated using
reformatted CT image
Guidelines for ramus as a donor site
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Guidelines for ramus as a donor site
As a result of these variables a rectangular piece of cortical bone about 3 – 6 mm in thickness may be harvested from the ramus. Length may range from 1 – 3.5 cm & height usually is not greater than 1 cm
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After harvesting graft may be stored in sterile saline or immediately fixed to the recepient site
Trabecular surface of the graft should be in contact with decorticated surface of the host bone
Donor block & recepient site contouring2 or more fixation screw sites should be
prepared for each bone block
Graft fixation
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Graft fixation
Holes in the donor block should be slightly larger than the outer diameter of fixation screws but smaller in diameter than the head of the screw
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A high speed lindemann bur or carbides are then used to recontour the block bone & smmothen any sharp edges or corner after it is fixed
Barrier membrane Not routinely used with cortical block bone grafts Indicated if more particulate or trabecular bone is
used Indicated if block graft is inadequate to fill the
entire space
Graft fixation
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Flap should be approximated & sutures placed such that there is no incision line tension or tissue ischemia
Graft fixation
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Stop smoking at least 3 days before surgery & until incision line has healed
Removeble soft tissue prosthesis should not be worn
Confirm to regular post operative follow up
Post-op instructions
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Intraoral block grafts4 months for maxillary recepient5 – 6 months for mandibular recepient sites
Particulate onlay grafts6 -9 months
Healing time
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Iliac crest
Tibia
Cranium
Rib
fibula
Extraoral donor sites
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AdvantagesLarge volumeouter portion of the graft may be
primarily cortical with major portion of trabecular bone underneath
Volume of the bone harvested permits contouring of 2/3 of the mandible or maxilla or filling a large bony defect
Relative ease of access & harvesting
Iliac crect cortical & trabecular block grafts
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Disadvantages
Rapid bone resorption of 30 – 90 % has been reported when conventional dentures are placed on top of the reconstruction
Curtis et al JPD 1987 ; 57 (73-78)
• post operative pain & gait disturbances
Iliac crect cortical & trabecular block grafts
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Complications
PainHerniation of the abdominal contentsFracture neuralgiaHematoma seromaInfection cosmetic deformity
Iliac crect cortical & trabecular block grafts
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Proximal tibial metaphysis provides an excellent source of trabecular bone
Primarily used with with BM & GBR procedure because major part of the harvest is trabecular in nature
Tibial bone grafts
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Disadvantages
Contraindicated in adolescents & children coz disruption of epiphyseal growth centre my occur
Fat content of the marrow is sometimes greater than that found in the ilium
Tibial bone grafts
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Complications
HematomaPost operative pain Infection Dhiscence ( incidence ranging from 1-4% )
Tibial bone grafts
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Sites Iliac crestScapula
indicationsBlood supplybto the graft site is severely compromisedRecipient bed is scarredCarcinoma patients who have undergone radiation
therapyDiv. E bone anatomy : discontinuity defects of the jaw
Vascular bone grafts
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Advantages
Maintains normal physiologic functionSimultaneous placement of implants with
microvascular bone flap reconstruction has shown an approximately 80% success rateusing Ti implants with a short follow up
Vascular bone grafts
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Disadvantages
Attaing primary graft stability is often difficult coz graft is often very spongeous with a thin cortical layer
Vascular bone grafts
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Refers to the formation of new bone between vascular bone surfaces created by an osteotomy & separated by gradual distraction
IndicationsMucoskeletal conditions such as post
traumatic defectsRepair of continuity defectsMandibular lengtheningMaxillary advancement
Distraction osteogenesis
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Contemporary implant dentistry by Carl E Misch ; 3 ed
Dental update 1997 ; 24 (332-337)
References
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